Case Manager

ConnectiveRx; Pittsburgh (Allegheny County); Hybrid; USD 42,000 - 61,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Life insurance

Disability insurance

401(k) plan

Paid time off

Holidays

Job summary

ConnectiveRx is seeking a Benefits Investigation Specialist to help ensure access to medications by working with medical insurers and pharmacy benefit managers. The role focuses on identifying coverage options and assisting patients with approvals, denials, and appeals as needed.

This position emphasizes education for patients and providers on insurance requirements, along with collaboration across pharma reps, doctors, and insurers to optimize coverage timelines and patient outcomes.

Qualifications

• Bachelor’s Degree in Health Care, Social Work, Nursing, or related area.
• Minimum of three years of health care insurance benefits experience.
• Experience with case management, utilization review, or patient advocacy is preferred.

Responsibilities

• Lead care coordination within an assigned territory, balancing patient and physician needs with program constraints.
• Coordinate information exchange between patients, families, providers, and insurers.
• Assist with insurance approvals/denials and Copay/Patient Assistance applications.
• Educate patients and health care providers on insurance requirements and options.

Skills

Verbal communication

Written communication

Mediation

Problem solving

Spanish language (plus)

Education

Bachelor's Degree

Job description

Overview

Being on medication is tough enough.We want to make getting it the easy part.Getting prescriptions to patients has become increasingly complex. When things get messy along the prescription journey, pharmaceutical manufacturers rely on us to untangle the process and create a clear path—allowing patients to build trusting relationships with their medication brands.

We’re not only committed to taking the pain out of the prescription process, but we’re also devoted to bringing the brightest minds together under one roof. We bring together diverse voices—engineers, pharmacists, customer service veterans, developers, program strategists and more—all with one vision. Each perspective and experience makes ConnectiveRx better than the sum of its parts.

Join our dynamic team as a Benefits Investigation Specialist and be a crucial part of ensuring access to essential medications! We seek a compassionate individual to engage with Medical Insurance Payers and Pharmacy Benefit Managers, playing a vital role in identifying and documenting coverage options for retail and specialty medications.

The Case Manager’s primary duty is to assist customers with chronic illnesses in their assigned territory by gaining access to their wellbeing needs, journey and treatment plan. The Case Manager collaborates and maintains consistent communications with internal and external partners (Pharma Reps, Doctor offices or Insurance companies) to formulate, affect, interpret operational practices to achieve resolution based on last stop coordination concerns. Case Managers use discretion for timely case resolution and maintains compliance based on matters of significance. The incumbent utilizes care coordination to address patient and physician concerns; obtains insurance approval for designated therapy and proactive plans to avoid the potential of delayed coverage by working with the patient, family, insurance, company, physicians, workplace, benefits administrators and individuals from other areas. The Case Manager facilitates the case management process along the healthcare continuum; advocating and contributing to the patient’s positive journey. Facilitate the case management process along the healthcare continuum. The incumbent assists with Benefit Investigations upon program need.

Responsibilities

• Takes the lead to manage the Care Coordination process within an assigned territory. Uses tact and independent judgment to balance patient and physician needs with the business realities and necessities of the program. Establishes and maintains professional and effective relationships with all internal and external customers (i.e., care coordination colleagues, care field team, patient advocacy groups, insurance company case managers, specialty pharmacies, physician office staff and office coordinators) while multitasking to coordinate, evaluate and advocate for options and services to meet the client’s needs.
• Assesses physicians’ needs and develops action plans that proactively mitigate delays in therapy. Coordinates the exchange of all patient-related information with internal and external customers (i.e., patients, families, healthcare providers, insurance companies, and specialty pharmacies). Effectively manages database including data on each individual, their insurance, coverage approvals, on-going coverage requirements and all patient and provider interactions.
• Keeps up to date with reimbursement process, billing/coding nuances, insurance plans, payer trends, financial assistance programs, charitable access, related resources, regional level and alternative resources.
• Assists in obtaining insurance approvals/denials and/or appeals for therapy. Assists patients and HCP with processing applications for Copay Assistance/Reimbursement and Patient Assistance Programs. Assists with ordering/triaging prescriptions for patient or HCP.
• Provides education to patients and health care providers, regarding insurance requirements, options and limitations necessary to initiate therapy. Provides education on relevant disease/product information.
• Exhibits a leadership role by demonstrating accountability for action plan execution, and energetically drives for success and results. Supports special projects as requested. (i.e., patients, families, healthcare providers, insurance companies, and specialty pharmacies).
• Identifies and recommends process improvements to support operational efficiencies. Effectively shares knowledge with other team members through orientation training, case studies, consultation for complex cases.
• Other duties as assigned.

Qualifications

• Bachelor’s Degree (or equivalent) in related area with focus in Health Care, Social Work, Nursing, preferred.
• Minimum of three (3) years of recent experience with health care insurance benefits, relevant state and federal laws, and insurance regulations.
• Proven ability to assess the ethics and legality of patient care.
• Recent experience in the case management process is preferred.
• Experience in a combination of home care management, case management review, utilization review, social service support, insurance reimbursement and patient advocacy, preferred.
• In-depth understanding of health care insurance benefits, relevant state and federal laws and insurance regulations, highly desired.
• Experience with data entry/computer literate skills, preferred.
• Exhibits a high level of case management expertise and demonstrated leadership skills
• Strong verbal and written communication skills, including effectively communicating with clients/providers/patients and employees of ConnectiveRx in a professional and courteous manner. Mediation, and problem-solving skills.
• Ability to speak Spanish is a plus.
• Ability to identify and handle sensitive issues with opposing opinions
• Proven ability to work independently and handle projects or multiple tasks
• Must possess the ConnectiveRx core values of: Passion, Innovation, Integrity, Accountability.

Competencies

• Analytical and Logical Reasoning: Analyzes information to decide the most proable cause of the problem.
• Decison Quality: Ability to make apporiate, informed and timely decisions using a combination of analysis, knowledge, experience and judgement.
• Communication: Ability to actively communicate key issues respectfully, ability to tailor messages to the apporiate audience.
• Service Orientation: Anticipate, identify, and address the needs of customers/clients, sometimes before those needs are voiced. Ability to be thoughtful, empathetic. Ensures that the customer's immediate needs or complaints are satisfied. Focuses on improving the level of service provided to external and internal customers.

Travel or Physical Requirements

• Perform primarily sedentary work with occasional lifting up to 20 pounds, and exerting to 10 pounds of force occasionally, and a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects.
• See, hear, talk and perform tasks requiring visual activity, manual dexterity, grasping and other similar tasks requiring physical activity and repetitive motions.
• Operate standard office and computer equipment.

Compliance Requirements

• Adhere to all Company Policies, Procedures, and other training consistent with ConnectiveRx's Information Security and Compliance Programs, including but not limited to the following compliances and regulations: SOC1, SOC2, PCI, HIPAA
• Maintain strict compliance with company and client policies regarding business rules and ethics, as well as applicable local, state and national federal laws

Compensation & Benefits: This position offers opportunities for a bonus (or commissions), with total compensation varying based on factors such as location, relevant skills, experience, and capabilities.

Employees at ConnectiveRx can access comprehensive benefits, including medical, dental, vision, life, and disability insurance. The company regularly reviews and updates its health, welfare, and fringe benefit policies to ensure competitive offerings. Employees may also participate in the company’s 401(k) plan, with employer contributions where applicable.

Time-Off & Holidays: ConnectiveRx provides a flexible paid time off (PTO) policy for exempt employees, covering sick days, personal days, and vacations. PTO is determined based on an employee’s first year of service. Employees also receive eight standard company holidays and three floating holidays annually, with prorations applied in the first year.

The company remains committed to providing competitive benefits and reserves the right to modify employee offerings, including PTO, STO, and holiday policies, in accordance with applicable laws and regulations.

Posted Salary Range

USD $41,800.00 - USD $60,600.00 /Yr.